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29-237 228 ACREBROOK DR BP- 2010 -0876 GIS #: COMMONWEALTH OF MASSACHUSETTS Map :Bloc 29 - 337 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING- PERMIT Permit # BP- 2010 -0876 Project # JS- 2010- 001298 Est. Cost: $1500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sg. ft.): 10018.80 Owner: PURDY MARILYN A C/O RAYMOND F J_ACOBS r.� ir+ €'n_A, - 0:��'nwcp 4p-nlicant; P : MA P.ILY N A,_C_ /O RAYM F JACOBS AT: 228 ACREBROOK DR Applicant Address: Phone: Insurance: 228 ACREBROOK DR (413) 387 -9706 FLORENCEMA01062 ISSUED ON :4/9/2010 0 :00:00 TO PERFORM THE FOLLOWING WORK .-INSTALL FOUNDATION DRAIN PIPE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House #; Foundation: ra Driveway Final: { ,. bF�� (,V (� I I �� L€� V,15 Final: f `�.'�. Final: " Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: — - - - -_ _ Insulation: Final: Smoke: Final: ,V7,S THIS PERMIT MAY BE REVOKED BY THE CITY OE -NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND Certificate of Occ U an 'nature: FeeType: Date aid: Amount: Building 4/9/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo r' 's City of Northampton O Building Department 'L0 212 Main Street PQ� Room 100 Northampton, MA 01060 phone 413 =587 -1240 Fax 413 - 587 -1272 " �x APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address 2 L-� This section to be completed by office Map Lot Unit Zone Overlay Distnct " } „Eirti St" Distri "ct CB, District SECTION 2 -PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record �,41e j 4/�',� Ti�C ®�'.(' 2,29 ,� C ��� Orc ��. T� �r�t�l Z Name (Print) Cup yly Add O� Telephone nature 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED= CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building ' 0 (aj Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number i This Section For Official Use Onl Building Permit Number: Date Issued: Signature: y q l0 Building Commissioner /Inspectorof Buildings Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning_ This column to be filled in by Building Department ' Lot Size Frontage Setbacks Front L--j Side L: U ._..V.. L: R: Rear w� F Building Height Bldg. Square Footage % - — Open Space Footage _ , % (Lot area minus bldg & paved par # of Parking Spaces -- Fill: volume & Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW 0 YES 0 IF YES, date issued:; i IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES 0 IF YES: enter Book Page and /or Document #; .__ B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued C. Do any signs exist on the property? YES Q NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding [O] Other [�] Brief Description of Proposed Work: �7cC a �f�T e �tr •>h PT !/t07y�a �' , n �Ta i l �f /�� �,' yi �J��% Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa. .lf t�y �t and.bl t d low re is IInc1!n I q:?iGt� a. Use of building: One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION Ta - OWNER AUTHORIZATION!-10 COMPLETED WHEN .. OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, AZ4/p d• �ft CO`Jf as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. , - —A Print Name 2 0 /0 Sign of ner /Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 8wl�eaiters€ klomlrrtronnenl Gi<inct#r y 3 �, ._.. ., .' ';' Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION I.Q. WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GiL. c.. 152, § 25C(6)),;: Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780 Sixth Edition Section 108.3.5.1. Definition of Homeowner Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be consid a homeown Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official that he /she shall be responsible for'all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, You may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature • T . The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigadons U 600 Washington Street Boston, MA 02111 www.mass gov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Pleas Print Legibly Name (Business orgmizationdndividual): Address: City /Statelzip: Phone. #: Are you an employer?. Check the appropriate box: Type of project (required) :. 1. ❑ I am a employer with 4.. I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time). * have hired the sub- contractors 2.. El I am a sole proprietor or partner- listed on the.attached sheet. 7. ❑ ems$ 11 ship � have no employees These sub - contractors have. .8. ❑ ��on wor for me m as enIoyees_andhave workers' king y ty . - - sanrA #_ IIButldmg addition workers' COTT�7 l�luaIIeC - co �' - 10, 5. E We are a coipoiation and its 0 Electrical repairs or additions am a homeowner doing aIl work officers have--- Ewcised their I LEI PIumbing repairs or additions I . myself [No workers' comp. right of exemption per MGL 12.[].Roof repairs insurance required.] t c: 152, § 1(4), and we have no 13.0 Other employees. (No workers' comp. insurance required.1 'Any applicant -that eheciz box #T must also fill out the section belowshowing tbeirworkcrs'- corr;msation policy information t Homeowners who submit tins affdavit.indi=ang they are doingall work and they hoe outside contrxiacs must subuut anew affidavit indicating such: t r 1 actors that check this box must attached sn additional shed showing the name of the sub- contractors sad state wisether ornottbose entities have employees. Ythe s conttactots have employees, they must provide their workers' comp. policy number. f am an employer that isproviding workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: . Policy # or Self-ins. Lic. #: Expiration Date: Job Site Address: City /StateiZip: Attach a copy of the workers' compensation policy declaration page - (showing the policy number.. and expiration date). Failure. to secure coverage - as required izndeerr Section 25A'ofMGL 152 can leadto the imposittton of crimm�l penalttes gf a fine up to $1,500.00 and/or one. -year imprisonment; as well as civil penalties in the form of # STOP WORK ORDER and a fine of up to $250.00 a.day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Tiivestisations of the I7IA for insurance coverage veitcation _ . I do'hereby certify under the parns and penalizes o f perjtay that - the informatwn provtdetf ab.org -tm- e- and -iorreri~ —:_ Phone #- Official use only. Do not write m this area, to be completed by city or town 'officiaL .City or Town: PermftUcense # Issuing Authority (circle one): J. Board of Health 2. Building Department 3. City/Town CIerk .4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two -year period shall not be considered a home owner." The building department for the City of Northampton wants person(s) who seek to use the home owner exemption, - to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the.building department be called to inspect work at various stages, which include foundation /footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure. to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform. work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above . ome owner /resid s signature requesting exemption) I will call to schedule Al required building inspections necessary for the building permit issued to Date — /W , 7 8 2-010 Address of work location ZU A C` 61 ' D`. ���or�r► -C ,/�!`j m V) c - u -A n L C r i O {-, :3 0 rp n 4 3 : 4-) i L L rII 1 L / \j O �O \�/ N � � C �t Q N N N m c O L N